Ophthalmologic Examination Integrated
Oh, there she is. OK, great. We'll keep continuing to work that out. Thank you, Dr. Lehman. Well, let me get us kicked off. My name is Robin Sitten. I'm the eLearning program manager for Perkins eLearning. It's always a pleasure to welcome you to our ongoing webinar series.
Today is Tuesday. It's February 21, 2017. And today's presentation, Ophthalmologic Examination Integrated with Functional Aspects of Cortical Visual Impairment, part of our ongoing discussion of CVI that we participate in throughout our program.
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Today's presentation by Dr. Sharon Lehman, who is Chief of Ophthalmology at Nemours Children's Clinic in Dover, Delaware, addresses the role of the ophthalmologist in a multi-disciplinary team approach to working with children with cortical visual impairment, or CVI.
Before we get started, let me just review a couple of things about the technology. As many of you know, we keep noise levels in control by muting your lines. Shortly we will replace this chat window with a question and answer space, and we encourage you to post your questions as they occur to you throughout the webinar. We're going to address all the questions at the end during our Q&A session.
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Sometimes our video connection with Dr. Lehman may not be in sync. This is usually an issue of bandwidth. It can be on your end, our end, or her end. Wireless connections can be sketchy, so if you find that happens, it usually correct itself shortly. And if you find it a little disturbing that it's not in sync, you can always minimize that window.
This event is being recorded. It will be available tomorrow on our website, including a version of the slide presentation that we're showing today.
We'll ask you if you poll questions throughout the presentation, just to kind of gauge where you are in your practice and what you have learned about the children or students that you work with.
It's my pleasure to introduce today's speaker, Sharon S. Lehman, M.D. She is Division Chief of the Division of Pediatric Ophthalmology in the Department of Surgery at Nemours Children's Health System in Delaware. A clinical professor of Ophthalmology and Pediatrics, she is also the Robison D Harley M.D. Endowed Chair of Pediatric Ophthalmology. And it has really been a pleasure working with you, Dr. Lehman, on getting this started.
I'm going to go forward one slide so we can meet our participants. It's always good to know who our audience is today. And [INAUDIBLE], if you could bring that first poll into the window, we'd like to just know a little bit about how you define your primary role in working with children who have CVI. We'll have some choices. This is actually poll number two, [INAUDIBLE]. We need poll number one. Thank you, sir.
And I will read them, as well, for those of you who are using magnification. It just helps us move through them a little quickly. So which of these would you say describes your primary role with students who have disabilities? Some of you have introduced yourself as teachers of the visually impaired. Are you an orientation and mobility instructor, or speech language pathologist, a special education teacher, or a general education teacher, an occupational therapist, a physical therapist, a parent trainer, or educator? Are you a parent or a family member, an administrator or a paraprofessional?
And of course, today, we also want to know if you are a practicing ophthalmologist or optometrist. We don't have a space for that, I'm afraid. Could you please answer in the place that kind of best fits-- you know, maybe I guess we'll have to say administrator. I apologize for that. We should have had that choice on here.
But we are seeing probably about 60% teachers of the visually impaired and also some people answering an administrator, as I ask. Sorry about that. We'll correct that in our records in that, and that's for the purpose of this poll, representing those of you who are practicing physicians.
A few parents on today, as well as a couple of other service providers and therapists, so that's nice to m, O and Ms, physical therapists and occupational therapists tend get very involved in CVI students.
Great. Let's go ahead and take that and I'll give the floor to you, Dr. Lehman. And I'll check back in at our next poll.
Thank you for the [INAUDIBLE] to participate this morning, and I'm very happy to see the range of people who are attending this webinar, I learn as much from you as hopefully you learn from me, and I actually learn more from my families and patients.
We're going to start with a case study to demonstrate what I think is currently going on, hopefully what we, meaning families, teachers, multidisciplinary team taking care of children, and the pediatric ophthalmologist.
We're going to start with a 12-month-old 23 week premature infant who has a tracheostomy, history of retinopathy, prematurity, who was recently diagnosed with cerebral palsy. And the child's mother is concerned that the child looks past her, stares at lights, and looks away when reaching for an object.
Mom went to see the pediatric opthalmologist, and the opthamologist's report stated that the impression was that the retinopathy of prematurity had resolved and that there was a normal eye exam, and recommended a one year follow up. I would imagine that some you have seen reports like this from your pediatric opthalmologist.
We're learning more about CVI and what we should be trying to help with our patients and families and multidisciplinary teams, and this slide shows what the pediatric opthalmologist exam should include. It should include a history, and that history should be focused on the child's visual behavior and characteristics. We need to validate the parent's observations-- we're going to talk more about that later in the webinar. We want to learn parents' expectations for their child.
We want to perform a complete eye examination. We want to provide a medical diagnosis, and very importantly, medical necessity. We want to refer the child for services for the visually impaired. We want to make recommendations, but we don't want to make just general recommendations. We want to make recommendations tailored to the individual patient, and we'll talk about that more.
We want to provide information to the patient's team. We want to provide educational materials, and if possible, support group information. And we also want to provide opportunities for parents to ask questions.
I'm first going to talk a little bit about how we examine children. And I have a new way of looking at the exam for children with cortical visual impairment. It somewhat follows the structure of phase one, phase two, and phase three classifications of cortical visual impairment. And as many of you know, that is from Christine Roman's work, phases two and three.
The first exam that a pediatric opthalmologist might do is number one, a history-- and I use a history that is looking at the characteristics of CVI. And it is modified from Christine Roman's work. The exam that we would do is looking at the child's visual acuity, pupils, the external exam, the interior exam. We look for alignment of the eyes and how the eyes work tracking objects, and then we check to see if there's any significant refraction or high nearsightedness, farsightedness, astigmatism that might need correction.
The next level of the exam focuses-- certainly it includes, like the first exam did, which is the modified questionnaire for the history and the structural physical exam, but it focuses more on a child who can do a little bit more, either by age or by impairment.
And we might be checking things like the ability for the child to focus on objects at near. It's somewhat more common in children with CVI, especially children with cerebral palsy might have difficulty focusing and they might need glasses for that reason, even if they don't need glasses for distance.
We try and check convergence, visual attention, fixation, how does the child use their visually guided behavior. We look for latency or delay in response to the objects, or in the visual task. We look at saccades, which are quick refixation movements, and pursuit, which is a smooth following of objects.
We would look for directionality of a line, and there I'm showing a test for directionality of line, where the child tries to put a card through a slot. And then we will change the orientation of the slot to see if the child can respond to that change in the axis and change the card orientation to get it through the slot. This tests not only the child's ability to see the change in the directionality of line, but it can also help to show us if the child has fine motor issues getting the card through the slot.
And then we might check contrast sensitivity. These two tests are from Lea Hyvarinen Many of you who are teaching the visually impaired, and others, may may know her in her contributions to children with visual impairment.
The third test is that of an ophthalmologic exam 3. And it focuses on a higher level function. And it works to include the number one and number two exams, and then it also includes higher level functions being tested-- executive functioning, figure ground skills, comparison of size and shape, and visual center.
And these are all things that children may have difficulty with. And the first object there with the crossing of the lines just shows executive functioning knowing-- going from left to right and top to bottom. At the bottom there, there are some shapes, and we're trying to see if the child can compare those sizes and shapes.
And this is just a graphic of these different structures of eye examination that could occur, based on the child's function. And then the low function, high function versus phase 1, phase 2, and phase 3. It's just trying to organize a way of thinking about cortical visual impairment, and how we would examine children with cortical visual impairment.
I think it's really important to know that we each in the multidisciplinary team have a reason to be there. I think it's important to know that my examination is not a substitute for an evaluation by a TBI. I cannot do a survey or inventory of a child and their cortical visual impairment. I don't have, personally, the time to do that. It's a lengthy examination.
And that's what the teacher the visually impaired is there for. And they're there to use their expertise for that child and how that child is going to use their vision and learn. Get an education. It's also not a substitute for an occupational therapist or a physical therapist, or a learning or reading specialist. Things that I've talked about before are my job in that multidisciplinary team.
I'm glad you mentioned--
[INAUDIBLE]
Yeah, let's have another poll. I'm glad you mentioned the multidisciplinary aspect. And here's a question we have, particularly for the parents and family members who are on the call today, to ask you to think about your own interaction with your child's ophthalmologist. And to let us know, on this scale, do you consider yourself and the doctor strong partners in your child's visual help.
Or maybe you might say, we work well together, but sometimes we disagree on educational strategies. Or perhaps you feel like your ophthalmologist understands clinical health, but doesn't understand the educational supports. Would you say that in your eye care practice you see several different doctors, who you don't have one primary ophthalmologist or eye health professional?
Then there's two other choices. Would you say you've changed practices many times looking for a strong interaction? Or would you say you have little or no personal interaction with the ophthalmologist? And right now, Dr. Lehman that seems to be the leading answer. About 50%, now almost 60% of people who are answering that, feel that they have little to no personal interaction with their ophthalmologist.
Though we are seeing about 10% who say they're very strong partners in their child's visual health. And a middle range there, about 14% saying they feel like the doctor's understanding clinical help, but isn't board with some of the education supports. That's an interesting array of responses. Thank you guys for sharing that.
I think we can go ahead and move on to the next slide.
Unfortunately, I'm not surprised by that response. And I think that one of the reasons I'm here today is to try and change that. There are some of us in pediatric ophthalmology who are trying to get pediatric ophthalmologists that are educated about cortical vision impairment, because we weren't educated well. I'll talk a little bit more about a survey that I did in pediatric ophthalmologists and actually TBIs in-- about their attitudes about cortical visual impairment. And we need your help. All of those of you attending the webinar, and your colleagues, to help us with that.
First we're going to talk about-- when taking a history from a family and what you should expect from your pediatric ophthalmologist. I try and use the question of, please tell me about your child vision. I often find that I find out just about everything I need to know before I take it before I formally ask the questionnaire questions, just by asking the child. Because there's no better expert about a child than a parent, and I would say often the TBI and other parts of the multidisciplinary team. But parents know their children, and we need to make sure we're listening to them.
My questionnaire is, again, modified from Christine's work. And it really looks at the characteristics. And it helps me to make the diagnosis. Because the diagnosis is somewhat based on the child displaying these characteristics. It makes it very easy, with the electronic medical record, to ask questionnaires like this, and to have them in the electronic medical record.
Who is the multidisciplinary team? Every year, often when I go to the pediatric cortical visual impairment meeting, I find that I add to this list. So please do not be insulted if you are not on the list, and I must have had some-- I usually have orientation and mobility on there, I apologize. It must-- when I reformatted this slide, I think that fell off somewhere. But orientation and mobility specialists are definitely on this multidisciplinary team. And as I said, it grows every year because of technology and specialization helps these children.
So just to review-- what are we looking at in a level 1 or exam number 1? Basically we're doing the modified questionnaire asking the parents their impressions of how their child uses their vision. And we do a basic ophthalmologic exam. We're ruling out structural eye abnormalities or confounding ophthalmologic factors that may influence the child's vision.
We're determining whether they need any optical correction or glasses. We're determining any necessary medical or surgical treatment that's necessary for the child. And this is often used with a child with limited visual response, who's learning to use their vision. And I think this melds well, whether it's a child who is six months old who has cortical visual impairment, or if it is a teenager after a traumatic brain injury who is at a phase 1 with their CVI.
Then the next level of the exam includes what the first exam did, but it adds additional aspects as the child is able to do more. And again, this is a child with higher visual function learning to use their vision more effectively along with their other functions of daily life.
And finally, the highest level, in exam 3, where we include everything from exam 1 and exam 2, but then we're looking at a higher level functioning. And this brings in what some people might call cerebral or cerebral visual impairment. That's a commonly used phrase in Europe. And it's probably beyond this webinar to talk about the issues with naming. And that is a big controversy, as to whether we call it cortical visual impairment or cerebral visual impairment. I find in the United States, often people and especially opthamologists will use cerebral visual impairment to describe higher level functioning problems.
Again, this is just a graphic showing the different levels of exam, which correspond to low function to high function and then phase 1 to phase 3.
The-- again, we're looking at what my exam should include. And I bring this to you hoping that you will help us by trying to educate the pediatric ophthalmologists. I think that you will find-- and I'll show you the statistics later on-- that most pediatric ophthalmologists want to understand cortical visual impairment better, and to serve their patients better.
I have, in my practice, teachers os the visually impaired or occupational therapists, I'm in a tertiary care center. And they will often come to the visits with the families and I have been educated by them in my care of children with cortical visual impairment-- or other types of visual impairment.
I think that in a friendly way, in a positive way, to help the pediatric ophthalmologist either with language that the child needs written in their medical record. I've been educated about a patient and what they need, and the terms that we need. We need to remind them-- pediatric ophthalmologists-- that we need to make the diagnosis of cortical visual impairment.
We need to document the medical necessity for services for the vision. Because in most states, only the medical doctor or the ophthalmologist can make that medical necessity. I think that it helps to educate them about what a IEP is. I now, at the end of my visit with a family, I always try to remember to say, let's look at what I'm going to write for instructions. What do you need for your IEP? What's changed from last year?
And then I try and tell them, if I'm not going to be seeing you for a year, and the child changes classrooms or schools, if something comes up where they're trying something different, contact me. And I can forward that instructions to you so you can share it with school for the child's IEP.
And again, I think that these are all things that, as pediatric ophthalmologists, that we should be doing for our patients. And we need your help in trying to help the ophthalmologist get to that point.
We're going to go back to this child, who is displaying some of the characteristics of cortical visual impairment. We always want to bring it back to the patient. And this child-- the mother is concerned that the child does not look at her face. He looks past her. And many of you already know, but children with cortical visual impairment, we think, have difficulty locating the object of regard.
Often when you're looking at something, and you can try this right now at home or your office or wherever you, and look at one object. Like, I'm looking now in this room straight across at a chair across the table from me. And everything else in the room is a little bit blurry. And that's because my brain is telling me that that chair is the object of regard.
And we think that children with cortical visual impairment, sometimes the way their brain is working that it's not helping them to find that object of regard. And in this case, we would give this mother help with trying to give her child cues to look at her face, or to look at another object by using movement, sound, with certain objects we use vibration or movement or a flash of-- a light that goes off and on to attract the child's vision.
The child tends to stare at lights-- children with cortical visual impairment sometimes respond better to high contrast situations, and they're staring at the light because of the contrast. So if you offer them other things to look at with high contrast, you may have luck in getting them not to stare at the light.
And this child uses their peripheral vision, or that when they reach for an object, they don't actually look at it. And that's often-- some of you may be familiar with the term eccentric fixation, or the fact that the child doesn't have to look at the object. Or possibly they're using their side vision to look at the object.
So again, this was what we talked about at the beginning of our slides, in that the child saw the ophthalmologist, the mother told the ophthalmologist those concerns. Sounds like the ophthalmologist just did not address those issues, and felt that the child had retinopathy prematurity that was resolved in a normal eye exam. Did not refer the child to vision services, did not try and help the family with suggestions for ways to help attract the child's visual attention and to help the child be more effective in using their visually guided behavior.
So what should have been the report impression and diagnosis? Well, the impression should have been that the child has cortical visual impairment. The child has a severe visual impairment, to help qualify for services. But certainly the child has retinopathy prematurity, had stage 2 in both eyes, and it's now resolved.
That the child has cerebral palsy, because that certainly will impact this child's behavior and what they can do. That the child was a formerly premature infant, and that the child has farsightedness or hypermetropia of both eyes, not requiring correction.
And we're going to take a break for characteristics of CVI audience poll.
Thank you. Thanks. So many of you may be familiar with some of the typical characteristics of children with this condition. Some of you just may know what you've observed. This is a multiple select poll. You've probably seen many or all of these. So which of these behaviors do you observe in your students with CVI?
Do you find that they're attracted to a specific color? Attracted to lights, as Dr. Lehman mentioned. Do they seem to have difficulty finding one object when they're looking at many objects? That was a good example there of how our vision kind of blurs away, so we know what we're trying to find? Do you see a slow response time, or slow to react? Do they tend to look away from an object before they can reach for it? And do they tend to use peripheral vision rather than central vision?
So many of these topics that Dr. Lehman just described, and as you can see, almost everyone is saying they see them all. Certainly light attraction and latency, that slow response time, very strong attraction to a specific color, and having to look away before reaching. I've seen that myself. 90 percent of you saying you see those children being attracted to the lights as something they prefer-- seem to prefer-- to look at. So that's really interesting. Thanks, [INAUDIBLE]. Glad to move on.
I think that the characteristics as described by many different people now-- Christine Roman, Dr. Dutton-- are really important in making the diagnosis. And I think that what we can do and we're going to get into that now-- how can we help the pediatric ophthalmologist learn about CVI?
And we need them to make recommendations. So we need them to learn about CVI, and then we need to give them tools to be able to use to make recommendations. And I think that the work of all of the trailblazers in cortical visual impairment is that we want to use the characteristics and give practical recommendations based on those characteristics. Some may be more important in certain children than others. But we want to use the characteristics and specialize it for that specific child.
Going on with the ophthalmologist's report should have said-- first, and most importantly, we need to treat the underlying medical conditions that may be causing the cortical visual impairment, if there's something actively going on. A child who has seizures may have cortical visual impairment from the seizures as part of their global neurologic problems.
In most children, cortical visual impairment is a subset of their global neurologic problem. So the child's having significant seizures, then we have to treat those underlying problems. The same thing with the child who may be suffering from hydrocephalus. They need to treat that hydrocephalus to help improve the vision.
In this child, no glasses are necessary. But we are very liberal in giving children glasses. And we need to heighten the awareness that some children can't accommodate or look at-- use their ability to focus on objects at near for long periods of time unless they have some help. And for that, we give children either single vision glasses for near or bifocal glasses if they can use bifocals.
In this child, some of the recommendations we could have used were to get the child to use their vision to look at an object. And we talked about that earlier, where we used high contrast and brightly colored objects to get them to view the visual object. We could also use additional cues-- lights, sounds, vibration, movement-- to get the attention.
And some people have an idea that, oh no, we shouldn't use something that makes noise, because then they won't be using their vision. How I like to try and explain it is that we need those other cues so they can use their vision. Because that's going to help the child latch on to the visual object, by using the sound or the vibration or the movement.
And avoiding overstimulation for this child would be a common problem for children who are premature. They have just a decreased ability to accept stimulation. And it's really important that you remember to back up, and actually get out of the child's personal space sometimes. When we hold something really close to them, that may cause them to shut down, because they can't handle that level of stimulation.
So I often ask people to, if they're showing the child an object, to move it back one to two feet from where they have it, and see if that improves the child's ability to look at that visual object. Overstimulation usually improves as a child gets older, and they're able to take in more stimulation. But you'll just cause them to shut down and nothing will occur if they're overstimulated.
We want to make sure we're providing support for the child, for their body, and for their head when they're performing visual tasks. Because if their head is falling down, they're not going to be able to look at the visual object. And if they're struggling with the support of their body and their head, they're not going to have any energy to use their vision.
We want to make sure that we're not giving the child verbal distractions when performing visual tasks. I have some older children and teenagers who tell me that it really distracts them when we're cheerleading them to perform their visual tasks. We ask them to perform the visual task. They start trying to do it. And then we cheerlead for them, and they can't accept the auditory and the visual at the same time.
And then you want to try and perform the task in a non-distracting environment. We want to refer for evaluation for services for vision for this child.
We want to make sure that the diagnosis medical necessity and recommendations get to the patient's team. That's going to be different for different situations. How we do that. But we need to make sure we do that.
We want to provide educational material about cortical visual impairment and support group information if possible. The family's questions need to be answered. We need make sure that they understand. We need to validate their understanding, and their agreement with the plan. We need to give options for them. And because what works for one patient-- family may not work for another.
And then we want to include contact information, so other members of the team can share the information and ask questions.
So this slide shows a survey question that I asked of practicing pediatric ophthalmologists. And I asked the pediatric ophthalmologists, would you like to learn more about CVI? Of the pediatric ophthalmologists that responded to the survey, 80% wanted to learn more about cortical visual impairment.
And I just think that that is wonderful news. They're open and we need your help to help educate them, as well as work that myself and others are doing to our national organization, the American Association of Pediatric Ophthalmology and Strabismus has taken this on as a project that we are currently working on to help knowledge about CVI.
And this was part of a project that I did. And I also asked the similar questions of teachers of the visually impaired. And you'll be happy to know that 80% of TVIs that responded to the survey also want to know more about cVI
The modalities-- how can we help? How can we help pediatric ophthalmologists? We're going to try and help by providing education and templates for the history and the physical exam, the diagnosis, the referral for services. Because referral for services is different in every state. And then we want to help them make recommendations and interventions for children with CVI.
We're going to provide recommendations and interventions. But they can't be cookie cutter. They have to be tailored to each individual child. We need to make sure that we're specific to each child's circumstances. What works for one family may not work for another. We need to be incorporated into the child's activities of daily living.
So we need to make recommendations for the different aspects of their life. We need to include environmental modifications. And then one of the things that is especially important to me is that we need to include developmentally appropriate recreation and play for older children. We sometimes will continue to show juvenile visual objects and targets and books to children that are teenagers.
And very often what we need to do is remember that they need age appropriate, based on their developmental abilities, to-- like audio books. We shouldn't be giving-- we shouldn't necessarily giving them a children's book if they can understand and be interested in different topics.
These are some of the templates that we might provide for pediatric ophthalmologists based on the characteristic. And then what are interventions for a child with a lower phase versus a higher phase? ? And many of you are probably familiar with similar things. How I have a list of these is what parents and teachers and families tell me they use.
Like one child, they wanted to know if the child can use a motorized chair. And this child does really well when someone walks in front of her, with a-- [INAUDIBLE] in learning how to use the chair, when they had her favorite color vest on. So they had a yellow vest that they would put on, so the child could follow with a motorized chair.
Another template is about latency. This is one thing. I'm going to talk over that. I apologize. No way for me to turn that off. Children can-- you need to provide them extra time. Children get frustrated with their visual tasks. They're performing visual tasks, and eventually start to give up when they are not given enough time to provide their visual-- to complete the visual task.
I'm just going to finish up with-- I need your feedback. I need your information about improving pediatric ophthalmologists' care of children with CVI. And we need you to help educate them in a friendly way, and give them language and understanding that they may not have to help your child. Or if you're the TVI or the other member of the team, the child on your team.
And please feel free to email me at that email with suggestions. I would love to hear from you.
Thank you so much. I'm just going to read that email out. It's slehman so S-L-E-H-M-A-N at nemours-- which is spelled N-E-M-O-U-R-S dot org. And we do have some time for questions. So we've got a lot of people on the call. So just enter your questions into the Q&A, and we'll address them as they come in.
I'll tell you one thing that I was curious about. In speaking about how doctors are not getting this information within the medical training, and-- Dr. Lehman, if you were building your medical school-- the Lehman Pediatric Medical School-- when would you introduce CBI into the ophthalmology curriculum?
Well, I think it would be good to start right beginning. I think in the past cortical visual impairment had a negative connotation in that we didn't think children with CVI could improve. And we know that's wrong now. And I think that that we need to change that at the basic levels of what we teach the residents. And we just don't do enough education about it.
In your case study that you presented, you used the term resolved, in speaking of the infant with ROP. And you said the ROP is resolved. Could you just explain more what you mean by that term?
Retinopathy prematurity is a retinal disease where, when the child is born early, the blood vessels have not had a chance to grow all the way out to the periphery of the retina. Until they do grow out out to the periphery of the retina, they are vulnerable to grow abnormally. And they can develop a line where it separates where the blood vessels have gotten to and where they haven't. That line can grow into a ridge. And then the abnormal blood vessels can grow on the ridge.
Most children, probably 80% of stage 1 or stage 2, this spontaneously resolves, where the blood vessels will go away, the ridge will melt down and flatten out. And then once that's gone, the blood vessels then grow out to the periphery of the eye.
And that is that a fairly new development to be able to resolve ROP like that? Did that happen early-- I've never-- I'm not familiar with a child, let's say, in the 40s or 50s, when they were born with retinopathy prematurity. I never heard that term, that it could resolve, is that new development?
No. No. Typically 80% of stage 1 or stage 2 retinopathy prematurity resolves spontaneously on its own. And that--
That's a relief.
So most children do resolve the retinopathy of prematurity. But we need to-- if it does not resolve and goes on, we need to catch it before it gets more significant. Because if it's not treated, it can result in retinal detachment. And once the child has a retinal detachment, they probably will have poor vision from [INAUDIBLE]. Even if it's [INAUDIBLE].
And you mentioned in your remarks that what we've learned about how CVI can-- children with CVI can improve their vision. And we have a question from the participants, can CVI be considered resolved?
Well, I think that there's a little controversy about that. I think that a child's visual function definitely-- there have been a couple of studies now that definitely show that children's vision can improve. And when they get to the higher levels of phase 3, the child may have very high functioning deficits. They may see 20/20. And you could have cortical visual impairment and have 20/20 vision. And have difficulty with higher level functions.
And I am certainly not an expert on whether you would say whether it resolves completely or not. But I think that phase 3 children-- sometimes their deficits are missed. And people will say that it's resolved, when they're not testing for those deficits. But--
Thanks.
I don't know the fall answer to that question.
No, but I think even addressing the fact that that is still something that's-- I do want to say "in dispute" as if it's a battle, but that is sort of an unknown. We speak of it in terms of resolution, but it's still an unknown.
Seeing a lot of questions that are, as you might expect, kind of specific to a particular child. And I think they're a good case study questions, so I'm going to address them. But let me just make a blanket statement that obviously Dr. Lehman is not able to give advice about a specific child that she is not examining. But I'll put these as sort of theoreticals in that sense.
So this is under the topic of disagreements between educators and practitioners about the student's actual condition. One teacher is saying, she has a student that has been diagnosed as almost total blindness, with little to no light perception. The teacher feels very strongly that this child probably has cortical visual impairment, and is wondering, as a medical professional, how might you proceed in that kind of impasse?
Well I think that it's possible that the ophthalmologist who sees that child doesn't understand that the child may have better vision than what they're getting. One of the problems that I see is that the testing of children-- no one gives them enough time to track an object. And they say, well, they don't track.
Well, they may show up something that's not very interesting for the child. They may not turn the lights out and use a lighted toy. That would really attract the child's attention. So I think that, again, a friendly, positive way, with the parents' permission, you may be able to talk to the pediatric ophthalmologist, if they're open. To say, in my observations of this child, I think that the child fits some of the criteria for cortical visual impairment. And these are those things that I see. And would you consider giving this child a diagnosis of cortical visual impairment.
That's nice. And so are there ophthalmologists now that are specializing in CVI? Are we there yet?
I don't think so. I think that some of us have a greater interest in it. But there's no special certification we're cortical visual impairment.
Sure. Is there a way of finding an ophthalmologist who has that, at least, knowledge or interest? How-- would you just ask as you're making inquiries?
I think so. I think that asking families that you know if they've had a positive experience. Hopefully you'll be having-- will make it such that you don't have to ask that question. [INAUDIBLE] In the American Association of Pediatric Ophthalmology and Strabismus that we do that. And that you won't have to ask that question. But until then, I think taking people that you know, taking their recommendations and asking when you call for the appointment are great ways.
One member is noting that an ophthalmologist had told a family member that in order to diagnose CVI, you needed to do an MRI. That's not entirely true, would you say?
Well, it's very unusual to have cortical visual impairment without and MRI being abnormal. I'd say that that is a very small, very small group of people, who would have cortical visual impairment and nothing at all on the MRI. So I would say that-- do I feel it's absolutely necessary to have an MRI? I would say if the child had the characteristics, then I would say that I may diagnose just on the characteristics, if there was a reason that an MRI couldn't be obtained. I find it very unusual in this day and age that a child that's coming to me with cortical visual impairment has not had an MRI.
Hmm. Okay. And that that will illustrate abnormalities in the brain, bleeds in the brain, that's what that MRI is going to show?
Going to show changes in the brain. One of the biggest groups that we have is children who are premature. And they will show what's called PVL, periventricular leukomalacia or atrophy, where they've had a previous hemorrhage. So there'll be signs even if the insult was remote. There will be signs on the MRI. It's very unusual to have CVI without that.
Thanks, that's helpful.
Is it appropriate for a parent to bring with them objects from home that they have found that the child is attracted to or tends to track?
That would be wonderful. Because you have to remember, it's an artificial situation in doctor's office.
Sure. The child's already nervous. Yeah.
Or they're sleeping. And it's very [INAUDIBLE]. They changed their seizure medicine last week and the child's really zonked. I sometimes tell families that that doesn't matter. I really need to hear what you observe. And that sometimes tells me more. Because it's an artificial situation, and we're showing them targets that they don't know or don't like. So I think that's a wonderful idea.
Oh great, thank you.
We have a question about optic atrophy. If you could speak a bit about optic atrophy and whether that's another condition where vision can be rehabilitated or improved over time, or is that considered a static condition?
Optic atrophy, when we look into the eye, we see that the optic nerve is pale, or whitish. Usually the optic nerve appears a nice pink color. And the optic nerve takes the electrical message from the eye to the brain. Your eye takes a picture, the optic nerve transmits that picture, or energy, from the eye to the brain.
And when you have damage in the brain, it often is followed by atrophy. And that atrophy extends down through the optic nerve. It can occur, and does occur, in many children who have cortical visual impairment. And it may be a co-morbidity, or another reason that the child doesn't see.
You cannot predict based on how an optic nerve looks whether a child will have vision or not. So you still have to assume that the child sees, and test that child. The sort of things that you can do as interventions or recommendations is that sometimes when you have optic atrophy, you have poor contrast sensitivity. Meaning that, you need things-- visual targets-- to be crisp black and white or bright colors. That'll make it easier for the child to see.
Because if you think about it, much of our world is gray. It's different shades of black and white, or tan. As I look around the room I'm in, the table is tan, the chairs are tan, the walls are tan. This would not be a great room for somebody who had poor contrast sensitivity.
So those are-- and then, if a child does have diminished visual acuity, you can enlarge objects or do low vision for that child. So there are ways to help that child. Optic atrophy is usually a static thing. It occurs from the insult. It will stay that way, and that only usually gets worse if there's another insult.
Interesting.
Let me shift gears for just a minute. We've got some questions more about the educational aspect of your topic. Do you find-- this is somewhat of a leading question-- but do you find that physicians need a little bit more education on IEPs, what an IEP is, and why it's important? How are they getting that information if they are not themselves parents of a student who has an IEP?
Well, I think that we're trying to do that education now. I did not receive any in medical school or my ophthalmology residency, training about an IEP. I think that pediatricians are better educated about this in their pediatric residencies. You have to remember that pediatric ophthalmologists went through an ophthalmology residency, and then did one year of pediatrics ophthalmology fellowship.
So we don't get that training. And we're trying to make that better. Again, APOS, our national organization, is trying to help pediatric ophthalmologists understand what an IEP is, and the other types of help that children get. So we cab--
And by the same token, how can we educate our school districts on the importance of these evaluative vision exams?
Well I think that in my experience, the schools and teachers of the visually impaired insist on an eye exam. And I think that they're helping to make sure these children are getting the help that they need. We need to do a better job of that in what we do. But I think it's important for the pediatric ophthalmologist to be very specific in their--
I had a family who-- they wouldn't give-- they wanted the child to use a combination lock, when it really wasn't appropriate for the child's vision. And you would think that just a parents saying, my child really can't use that combination lock, would be enough. But it takes my writing that down that the child needs to be-- it's medically necessary for that child to have a key lock to get those recommendations. So those are the kind of things we need to help families get.
Yeah, and that's a really interesting example, too. Because it's non-academic, and yet that's a real you know day-to-day thing. And you can see how a school district or a school administrator might just sort of sigh and say, why has that got to be everything? To understand that because of the condition of this child has, they can't use this kind of device.
I really appreciated you talking about the older children, and how the therapies and the intervention need to grow with them. I think we're learning a lot from these children who are now maturing, especially the children who-- the young people now-- who are so articulate and who are able to really participate in their own evaluations and therapies.
And it made me wonder why you were speaking, at some point as these children mature, adult ophthalmology is going to also need this kind of understanding that the pediatric ophthalmology has begun to embrace. And I'm wondering just what your feelings are about that branch of practice, and how these young people will begin to be received as they move out of pediatric care?
Well I think there's a lot of challenges for children as they get older, and certainly transition is one of them. Another thing that I find that children with CVI have is learning to drive. If they are able to. What's more novel and complex than learning to drive? I think that we need to all understand how CVI affects a child or a teenager or an adult in their life. And the accommodations.
And often the combination are not that difficult to make. But we need to help them to meet those challenges. And I think it's very important that as we help the pediatric ophthalmologists first, that we then offer that same education to ophthalmologists who take car eof adults.
Adults. Mm-hmm.
Do you have any comment on vision therapy, the practice of vision therapy, particularly for convergence, higher lever functioning, things like that? Where does that fall in this conversation about CVI?
Well, I think that-- again, I think you have to be specific to what the problem is. I think if the child has intermittent exotropia where their eyes intermittently drift out, that eye exercises can help that problem. And I have handouts what I give to families so that, either in occupational therapy or at home, they can do those exercises. Most of these children don't need another therapy to go to.
But certainly optometric visual training for convergence exercises is an option if the family can't do it at home or feels that they need extra help with that. So I think that those are all options. And again, depends on what part of the country you're in, or what resources are available to you to get that done.
I think that children who have reading problems need a reading specialist. I think that vision training is not-- there's only a certain amount of money that you have to get a child services. And a reading problem needs to be treated by a reading specialist. So again, it depends on what you are doing the vision therapy for.
Or educationally, for executive functioning, again, I think that that can be learning left to right and top to bottom is a classroom activity. And is probably best taught in an educational manner. Occupational therapy can also help with some of those things. But I think it has to be very specific to what the task or what the problem is.
Thank you. We need to wrap up at this point. We were just starting to get going. And I did try to bundle a bunch of your questions for people who had questions that were very similar. If I did not get to your question, please email Dr. Lehman, she's generously given us her email address. I want to just sort of close with a comment.
I'll go ahead and say Laurie's name. She said-- she just wanted to thank you, and that it's happy to see you provide families with support information and educational materials. She adds, "I've heard from too many parents whose child was diagnosed with CVI or blindness, and following the diagnosis, the doctor walks out of the room with no resources." So I really appreciated that sentiment, and I think it sums up a lot of the thank yous that are coming in to the box.
Thank you again for your time. Is there anything yet to say about the 2017 Pediatric Conference that we can share? I don't know if it's been scheduled.
It's in Omaha in early June. I'm thinking around the 8th or 9th this year. It's a great meeting. And I would encourage folks to go. It's a Children's Hospital of Omaha. And you can just Google it, and get the information for registration. It's a great, great, multidisciplinary meeting. We all learn from each other.
Great. And we'll try to put the link onto our website as well with the recording and the presentation itself here. We've got a lot of thank yous coming in. So again, let me thank all of you for participating. We had over 70 individuals at one point, and that really does make the conversation. And on behalf of all of us here at the e-learning team, my partners here online with me and Dr. Mary Zatta, we just always want to thank you, and we'll see you next month. Take care.
Thank you.